Surgical Repair of Rotator Cuff Tears
Many patients will improve with appropriate rehabilitation of the rotator cuff. However, some patients will have continued symptoms despite adequate rehabilitation and may require surgery. Arthroscopic shoulder surgery should be used to both define and diagnose the exact nature of the tears. In most cases, the problem can be treated using specially designed instruments working through very small incisions with a minimum of discomfort and without the need for a hospital stay.
One of the obstacles to surgery of the shoulder (unlike the knee) is that a bony and muscular “envelope” surrounds the shoulder – the shoulder blade, or scapula acromion. The rotator cuff muscles originate on the scapula and surround the socket and humeral head under this acromial roof. The larger deltoid muscles originate from the surface of the acromion, and form another muscular barrier to the cuff as well. In short, the rotator cuff is “protected” in the front, side and back by the deltoid muscles, and is inaccessible from the top owing to the bony acromion.
Historically, surgeons had to make large incisions in the skin and split and move the deltoid muscles to gain access to the rotator cuff. Serious and debilitating complications developed if the deltoid muscle origin did not heal back to the acromion. Moreover, in cases of larger retracted rotator cuff tears, working through a deltoid split can become a little like building a ship in a bottle—trying to work through the narrow mouth of a bottleneck to get to the retracted cuff tissue!
Arthroscopic shoulder surgery, or shoulder arthroscopy, is a valuable tool to treat rotator cuff tears. Using the scope, an experienced surgeon can use arthroscopic techniques to evaluate the entire shoulder joint and usually fix the tear through very small incisions using specially designed instruments and devices. It is a common misconception that tears that are large should not be repaired arthroscopically—in fact the advantages of visualization and complete access to the tear make such large tears particularly amenable to arthroscopic repair. The goals of repair are to restore normal and painless motion and full strength to the affected shoulder. This is achieved through following steps (follow the link at 1.02 to 1.33 min in this video)
- The rotator cuff tear is identified and loose, degenerated, and frayed tissue around the cuff edge must be removed back to healthy tissue. This process is called débridement.
- The edge of the cuff tear must be brought back to its normal position without undue tension. This process is accomplished using techniques called mobilization or, in larger tears, a technique called margin convergence.
- The tear must be fixed into place using specially designed suture anchors that allow the surgeon to approximate the cuff tear securely to the bone.
The results are most predictable in the hands of a highly specialized surgeon who is familiar with the various techniques and instruments and who performs this surgery often. This will maximize the benefits of the surgery and minimize the risks. The procedure can usually be performed within a few hours under general (or nerve block) anesthesia and the patient can be discharged to home with a minimum of discomfort. In addition, the scope allows the surgeon to take pictures and video to show to the patient what problem(s) existed and how the problem was addressed.
Is my rotator tear “too big” to be fixed using arthroscopy?
The primary advantage of all-arthroscopic repair is that it allows a surgeon “global” access to the rotator cuff and tear for adequate cuff evaluation, repair and fixation to bone. For this reason, the LARGEST tears are often that require the greatest degree of skill and familiarity with arthroscopic techniques. Surgeons who are familiar with arthroscopic techniques actually prefer to prepare and evaluate the cuff using the arthorscope, as this allows better visualization.
Are the results as good as with “mini-open” techniques?
Most of the recent studies show that in the hands of surgeons who are expert in all-arthroscopic rotator cuff repair, the results are comparable to open techniques. Specifically, the best results reported for open repairs are as high as 97% success. Recent articles reported on arthroscopic fixation using the latest instruments and techniques demonstrate 93% to 95% good and excellent results.
It is interesting that when massive tears deemed “irreparable” by standard techniques are addressed with an arthroscopic technique called margin convergence, the results can be favorable even if the tear can’t be fully repaired to bone.
What happens without surgery?
Persons who suffer from pain, weakness and muscular imbalances in the shoulder may lose valuable time from work, become progressively disabled, or worse – do permanent or irreparable damage to the rotator cuff or develop premature arthritis.
In cases of an extremely long-standing rotator cuff tear with shoulder dysfunction, arthritis can occur in the shoulder joint. This process is called rotator cuff arthropathy and can lead to severe disability and irreversible changes to the shoulder joint. Usually, if the process has gone unchecked for a long time, a rotator cuff repair is unlikely to be successful. Other surgical operations, involving replacement of the humeral head (also called hemi-arthroplasty) may be required to alleviate symptoms.
Will I recover or “heal” faster after arthroscopic rotator cuff repair?
All surgeries done to repair the rotator cuff, whether performed through open incisions or using the arthroscope, are designed to replace the rotator cuff to its original site, called the insertion. The sutures placed to hold the cuff would fatigue and break over time and the repetition of normal shoulder motion if it were not for the fact that the body “heals” the cuff to the repaired position with relatively normal tendon.
Most people feel better faster, but they are not technically healed faster after an arthroscopic repair. The rate of the healing process is not affected by the method used to repair the cuff, so the cuff will not “heal” more quickly if a less-invasive, arthroscopic procedure is performed. However, most patients feel better much sooner after an arthroscopic procedure because these procedures do not require the extra healing of the deltoid muscle and longer skin incisions. For this reason, a patient must be disciplined about adhering to a strict postoperative “rest” so that they don’t stress the repair before the body has completed the healing process, which goes on for several weeks and months.
Who should consider arthroscopic rotator cuff repair and shoulder surgery?
Arthroscopic or open shoulder surgery is considered for cuff tears when:
- Pain, weakness, and disability represent a significant problem for the patient, and inhibit his or her ability to perform the activities of daily living, overhead activities, or sporting activities
- The patient understands and accepts the risks and alternatives to the procedure
- An appropriate and comprehensive diagnostic evaluation has been performed and the nature of the problem is clear
- The surgeon is experienced and familiar with several techniques and treatments for shoulder injuries, including arthroscopic surgery and open (traditional surgery)
- The patient is capable and willing to undergo a comprehensive post-operative rehabilitation (physical therapy) program
The results of arthroscopic and open rotator cuff repair procedures are most effective when the patient follows a simple post-operative rehabilitation program. Thus, the patient’s motivation and dedication are important elements of the partnership.